1. Partnering with Colleges and Universities to Facilitate the PCMH Process R.W. “Chip” Watkins, MD, MPH, FAAFP Conference on Practice Improvement Greenville, SC 1 December 2012

2. Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. The following individual(s) in a position to control content relevant to this activity have disclosed the following relevant financial relationships: R.W. Watkins, MD, MPH, a consultant/employee of CCNC.

3. Patient-Centered Medical Home The PCMH is a model of primary care re-design intended to improve the quality and efficiency of primary care delivery

4. What we have… What we need!! Atul Gawande, MD

5. Features of PCMH Four common features in successful demonstration projects  Dedicated care managers  Expanded access to clinicians  Data-driven analytic tools  Use of incentives

6. Community Care “How it works”  Primary care medical home available to 1.2 million Medicaid patients in all 100 counties  Provides 5,000 local primary care physicians (94% of all NC PCPs) with resources to better manage Medicaid population  Not-for-profit networks link local community providers (health systems, hospitals, health departments and other community providers) to primary care physicians  Resources include 600 local care managers, 26 pharmacists, 14 psychiatrists and 20 medical directors to improve local health care delivery

7.  The state identifies priorities and provides financial support through an enhanced PMPM payment to community networks  Networks pilot potential solutions and monitor implementation (physician led)  Networks voluntarily share best practice solutions and best practices are spread to other networks  The state provides the networks (CCNC) access to data  Cost savings/ effectiveness are evaluated by the state and third-party consultants (Treo Solutions, Milliman) Community Care: “How it works”

8. System-Wide Results  Community Care is in the top 10 percent in US in HEDIS for diabetes, asthma, heart disease compared to commercial managed care.

9. Treo Savings Estimate Using the unenrolled fee-for-service population, risk adjustments were made by creating a total cost of care (PMPM) set of weights by Clinical Risk Group (CRG), with age and gender adjustments. This weight set was then applied to the entire NC Medicaid Population. Using the FFS weight set and base PMPM, expected costs were calculated. This FFS expected amount was compared to the actual Medicaid spend for 2007, 2008, 2009. The difference between actual and expected spend was considered savings attributable to CCNC. Treo Solutions, Inc., June 2011.

10. What is the Multi-Payer Advanced Primary Care Practice Demonstration Project (MAPCP)?

11. What is the Multi-Payer Demo?  The purpose of the Multi-Payer Advanced Primary Care Practice “demonstration project” (MAPCP) is:  To evaluate the effectiveness of the Patient Centered Medical Home (PCMH) model, when supported by both public (Medicaid and Medicare) and private payers (Blue Cross Blue Shield, and State Health Plan)  To utilize care management for these other payer sources

12. What is the Multi-Payer Demo?  NC is one of 8 states that was awarded an MAPCP demo  7 rural counties across NC were chosen to participate in the demo: Ashe, Avery, Bladen, Columbus, Granville, Transylvania, and Watauga

13. What is the Multi-Payer Demo?  To participate, practices in these counties must obtain PCMH recognition from the National Committee for Quality Assurance (NCQA) during their first year of the demo  In return for implementing the PCMH model, practices will earn incentive payments from the largest public and private payers in NC: CMS and BCBS-NC/SHP.

14. PCMH 2011 Overview (6 standards/27 elements) 1.Enhance Access and Continuity A.Access During Office Hours B.Access After Hours C.Electronic Access D.Continuity (with provider) E.Medical Home Responsibilities F.Culturally/Linguistically Appropriate Services G.Practice Organization 2.Identify/Manage Patient Populations A.Patient Information B.Clinical Data C.Comprehensive Health Assessment D.Use Data for Population Management 3.Plan/Manage Care A.Implement Evidence-Based Guidelines B.Identify High-Risk Patients C.Manage Care D.Manage Medications E.Electronic Prescribing 4.Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources 5.Track/Coordinate Care A.Test Tracking and Follow-Up B.Referral Tracking and Follow-Up C.Coordinate with Facilities/Care Transitions 6.Measure and Improve Performance A.Measures of Performance B.Patient/Family Feedback C.Implements Continuous Quality Improvement D.Demonstrates Continuous Quality Improvement E.Report Performance F.Report Data Externally Optional Patient Experiences Survey

15. Scoring Total 100 Points LevelPointsRequired Must Pass 1≥ 356 Must Pass 2≥ 606 Must Pass 3≥ 856 Must Pass Recognition requires achieving all 6 must pass elements with a ≥50% score

16. Recognition of Added Value Incentive Payments from Medicare  CMS pays a per member per month fee for each Medicare patient in practices achieving PCMH recognition through NCQA:  Level 1 = $2.50 PMPM ($30 each year)  Level 2 = $3.00 PMPM ($36 each year)  Level 3 = $3.50 PMPM ($42 each year)

17. Recognition of Added Value Increased Reimbursement from BCBS  Eligibility for the Blue Quality Physicians Program (BQPP), a recognition program for primary care practices that builds on PCMH recognition from NCQA  Once you qualify for the BQPP, BCBS will increase its fee structure by 10% or more for all of your BCBS/SEHP patients

18. Benefits of the PCMH Model Quality – Outcomes for seven medical home demonstrations  Fewer ER visits (15%-50%)  Fewer hospital admissions (6-24%)  Lower mortality rates  Better preventive service delivery  Better chronic disease care  Higher patient satisfaction Source: Fields, et al. (2010) and Reid RJ, Coleman K, et al. (2010).

19. Benefits of the PCMH Model Efficiency – Cost  Lower total costs of care - (6.5-22%)  Shorter patient wait times  Less staff burnout/turnover (10% Vs. 30%)  Higher staff satisfaction/productivity Source: Fields, et al. 2010

20. This is a No-Brainer!  So Why Aren’t Practices RUNNING to implement PCMH for themselves?!? 1.Time 2.Resources 3.Consultants are expensive 4.Fear a)Gov’t interference b)Loss of control/independence c)Change

21. Watkins. Journal of Medical Practice Management, Sept/Oct 2012, Vol 28:2, pp. 134-6.

23. Linville Gorge, Blowing Rock, NC

24. ASU Practicum in Primary Care ASU College of Health Science, School of Healthcare Management

25. Creation of Partnership with Appalachian State University PARTNERSHIP:  Recruit ASU students from School of Health Care Management  Develop curriculum, syllabus, website, core documents  Create new practicum course with internship opportunity  Teach students about PCMH, Provider Portal, Care management process  Send students out to practices to assist in attaining PCMH certification, BQPP cert and QI initiatives

26. ASU Practicum in Primary Care  Fall of 2011 – 5 students  Spring 2012 – 9 students – BSBSNC Foundation Grant Obtained  Summer 2012 internship – 8 students  Fall 2012 – 14 students

27. ASU Practicum in Primary Care  Developed curriculum, core documents, website https://sites.google.com/site/pcmhprac/ https://sites.google.com/site/pcmhprac/

28. ASU Practicum in Primary Care  Used the CCNC PCMH workbook, webinars  https://www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmh- resources/ https://www.communitycarenc.org/emerging-initiatives/pcmh-central1/2011-pcmh- resources/

30. ASU Practicum in Primary Care  Worked through curriculum and have weekly didactic meetings on ASU campus  BAA for HIPPA compliance  Students prepare PCMH PPT for “their” practice and give to group  Go through the Standards and hit high points  Students share successes/failures with facilitators/faculty  Placed students in field and worked with the practices  Students give PPT  Work with practices – develop “PCMH Team”, schedule time with team, give weekly assignments, follow-up, etc.

31. Quotes from Students  “This practicum has served as the keystone to my healthcare management degree. The practical experience I have gained as a student intern is incomparable. This project is on the cutting edge of the future of healthcare delivery. Considering my cross-functional background in psychology and healthcare management and my aspirations to be a primary care physician, this practicum has provided me with the integrative experience and the comprehensive perspective needed to pursue professional school and/or a graduate program with a unique perspective.” —Delvon Blue  “This internship has afforded me the opportunity to experience the practice management side of healthcare. Also, I had the privilege of working closely with physicians and staff as I learned about their views on patient care and corporate compliance. In addition, I learned how to present information to a team to encourage buy-in, how to work with people of different skill levels and positions, how to implement new processes and improve current processes within the practice, how to draft policies, and how to document the outcomes so the practice could receive the credit they deserve.” —Ashley Zachary

32. Program Growth  ASU School of Health Care Management has made the “Practicum in Primary Care” a CORE curriculum class  Students willing to spend 2 semesters with us get full credit for their internship (300 hours)  “Keeping the Medical Home Fires Burning” is a new initiative where practices that have been recognized work with students on QI projects

33. Program Growth  Remote Learning Initiative  Students work with practices within 3 hours of Boone  MOVI (secure) web-hosting  Face-to-face visits every 3 weeks or so

34. CCNC’s PCMH Efforts Beginning of MP Project

35. There’s No Place Like…

36. That’s all folks!

37. Partnering with Colleges and Universities to Facilitate the PCMH Process R.W. “Chip” Watkins, MD, MPH, FAAFP Conference on Practice Improvement Greenville, SC 1 December 2012